Contraceptive Pill Review

If you have been advised by the surgery to submit a contraceptive pill review, please use this form.

Contraceptive Pill Review

Contraceptive Pill Review

About You

eg. 1.75
eg. 60.6

Blood Pressure

Please provide a blood pressure reading if you have access to a machine.

For a list of validated home blood pressure monitors, visit www.bihsoc.org/bp-monitors or discuss with your pharmacy.

Please use date format: DD/MM/YYYY
/

Smoking

Smoking status: *

Smoker

What do you mainly smoke?
How many cigarettes do you smoke in a day? *
How many cigars do you smoke in a day? *
Would you like to give up smoking? *

If you would like help or advice to stop smoking, please visit NHS Quit Smoking.

Ex Smoker

What did you mainly smoke?
How many cigarettes did you smoke in a day? *
How many cigars did you smoke in a day? *

Contraception Pill Review

Do you regularly check your breasts? *

Please ask reception for our information regarding the importance of regular breast self-examination.

Cervical smear testing starts at age 25 years. If you are in this age group, is your smear test up to date?
Do you have normal periods (menstruation)? i.e. a regular cycle with no excessive or intermenstrual bleeding *
Please describe your cycle:

Please make an appointment to see your doctor to discuss your cycle if you have not already done so.

Do you know how to take your medication properly? *
How do you take your medication:
Have you suffered from severe headaches in the past 3 months?
Do you suffer from migraines?

Please make an appointment to see your doctor to discuss your headaches or migraines if you have not already done so.

Has anyone in your immediate family suffered from a blood clot in their leg or lung under the age of 45 years?
*